Healthcare Provider Details

I. General information

NPI: 1184706160
Provider Name (Legal Business Name): STEVEN JOHN FAHSEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W LAKE ST
LAKE MILLS WI
53551
US

IV. Provider business mailing address

119 W LAKE ST PO BOX 47
LAKE MILLS WI
53551
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-2912
  • Fax: 690-648-8219
Mailing address:
  • Phone: 920-648-2912
  • Fax: 690-648-8219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0003219
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: